An Integrative Approach to Addressing Childhood Overweight: Inclusion of Parenting Information in Nutrition Education Programs

Introduction

Childhood overweight is of growing concern, with as many as 15% of children between the ages of 6 and 19 being classified as obese (Centers for Disease Control, 2004). While there are a variety of approaches aimed at addressing this epidemic, research suggests that early prevention of weight gain is more effective than intervention after weight gain is established (Ritchie et al., 2001). To prevent childhood weight problems early in life, programs typically focus on teaching parents information about nutrition and feeding, such as the USDA funded Expanded Food and Nutrition Education (EFNE) and Food Stamp Nutrition Education (FSNE) programs, and the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program.

However, families participating in these programs face many barriers when attempting to make lasting nutritional changes, including difficulties with carrying out effective parenting strategies. While parents learn information for optimal child nutrition, they may not have the skills necessary to effectively make the changes in their homes. Further, nutrition educators may not be prepared to support parents in building the general parenting skills required to facilitate these changes. The study reported here used focus groups with nutrition educators to examine possible barriers parents and educators face in effectively changing child feeding behaviors.

Parenting

There is widespread empirical support for the role parenting quality assumes in children's development (see Teti & Candelaria, 2002, for review). The wealth of research in this area has consistently supported the benefits of an "authoritative" parenting style (Baumrind, 1973) that includes reasonable control, high levels of nurturance, appropriate limit setting, and clear communication patterns. In contrast, "authoritarian" styles are described by high levels of control, low levels of nurturance, and unclear communication patterns, and "permissive" styles are characterized by high levels of nurturance and clear communication patterns but low levels of control. Thus, where authoritative parents are sensitive and set clear and reasonable limits with their children, authoritarian parents display little warmth and set unreasonable limits with their children, and permissive parents set very few limits.

Research investigating the implications of these parenting styles on children's development has consistently linked authoritative styles to desirable developmental outcomes for children (see Maccoby & Martin, 1998 for review), although some variation is found across cultures (Bornstein, 2002). In essence, authoritative parents tend to have children who are physically, cognitively, and emotionally healthy. In contrast, authoritarian and permissive styles are both associated with a lack of self-control, social skills, and academic achievement.

Given the consistent and pervasive relations between parenting and child well-being, it is no surprise that programs regularly aim to improve child development outcomes by improving parenting skills (Cowan, Powell, & Cowan, 1998). Through these types of programs parents learn appropriate expectations for their children's developmental stage, suitable boundaries, and effective discipline techniques that have positive effects on their parenting behaviors.

Parenting Behaviors & Nutrition

Recent research has found that when parents attempt to improve their family's nutritional status, they struggle with resistance from their children (Birkett, Johnson, Thompson, & Oberg, 2004). The ways in which parents respond to such resistance is likely tied to their overall style of parenting and may have important implications for their children's nutrition and weight.

There is some evidence that parental feeding practices may be related to overall parenting style. Specifically, parents whose behavior is indicative of "authoritarian" and "permissive" styles tend to use ineffective feeding strategies linked with child overweight (Hughes, Power, Fisher, Mueller, & Nicklas, 2005), including rewarding good behavior with food, controlling or limiting the availability of certain foods, pressuring children to eat, and being overly permissive regarding food intake. Alternatively, parents who demonstrate behaviors associated with "authoritative" styles tend to exhibit more appropriate levels of control and more effective strategies for encouraging positive eating behaviors in their children (Hughes et al., 2005).

Overall, the relation between parenting and children's nutrition parallel those found in the parenting literature. Just as over-control (authoritative) or lack of control (permissive) is associated with negative social and cognitive developmental outcomes, this pattern appears to hold for children's feeding behaviors as well. Parents who put too much restriction on children's food choices, or allow children to have all the control, tend to have children who develop harmful eating behaviors and weight problems (Hughes et al., 2005; Patrick, Nicklas, Hughes & Morales, 2005; Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006).

The similarity in these patterns may point to common, underlying components of competent parenting. In essence, parents who have the skills necessary to set, communicate, and consistently reinforce reasonable limits with their children are able to foster an environment supportive of optimal development in all areas. Programs aimed at reducing child overweight and improving child feeding practices may therefore be most effective when they incorporate the teaching of parenting skills into their programs.

Nutrition Education Programs

Despite these findings, programs that focus on delivery of nutrition information are more common than those that also include parenting education. For example, USDA-funded nutrition education programs such as EFNEP and those funded by FSNE operate in all 50 states to improve the nutritional status of low-income families. While Adult EFNEP serves limited resource families with children and pregnant women from a diverse ethnic background (157,800 families served nationally in 2004; 33% white, 33% Hispanic, 29% Black, 3% Asian/Pacific Islanders, and 2% American Indian), adult FSNE is implemented by state agencies and Cooperative Extension services and serves food stamp recipients and those eligible for food stamps on a voluntary basis (No national data available: University of California Cooperative Extension (UCCE) FSNE program enrolled 6,696 participants in 2004; 34% white, 47% Hispanic, 13% Black, 3% Asian/Pacific Islanders, and 3% American Indian).

While a significant part of these programs is targeted at improving nutrition for families, the effectiveness of these efforts for children's nutrition may be limited by their scope. Classes are commonly taught by paraprofessionals and are strictly limited to providing information regarding basic nutrition, resource management, and food safety (EFNEP) and the messages of the Dietary Guidelines (EFNEP and FSNE). While the focus of these federal programs is mandated, narrowing the approach to focus solely on nutrition void of the family context misses opportunities to foster parenting skills necessary to enact behaviors that prevent child overweight. This perspective is consistent with the National Extension Parenting Education Model (Smith, Cudaback, Goddard, & Myers-Wall, 1994), which identifies seven critical categories of parent skills that are seen as fluid and dynamic. In other words, all aspects of parenting co-exist and influence one other.

There is no research to date exploring whether parents participating in these programs or the educators delivering the information see a need for parenting information. Further, if parents are expressing difficulties with parenting when negotiating changes in their feeding practices, it is unclear how nutrition educators currently respond. The study reported here used focus groups with nutrition educators to examine barriers expressed by parents attending nutrition education courses and educators' ability to respond.

Method

Participants

Ten nutrition educators (100% female) representing 10 counties throughout the state of California participated in the focus groups. All educators worked with FSNEP and/or EFNEP.

Procedure

Two semi-structured focus groups were conducted by the first author through telephone conference calls following protocol suggested by Morgan (1997). The focus groups were audio recorded and transcribed verbatim. Both groups were asked open-ended questions about concerns parents have regarding nutrition for their children and what they saw as possible barriers underlying these concerns. Based on their responses, follow-up probes were used to generate discussion about their ability to help parents overcome the identified barriers and what resources they accessed for information about these issues.

Transcripts were coded by a research assistant in three steps. In the first step, respondent answers were coded into two broad groups: "Questions/Concerns of Parents" and "Barriers for Parents." In the second step, the identified patterns within each group were organized into categories that captured the naturally occurring patterns of responses. In the third and final step, each category was reviewed for references to educator attempts to address the concern or barrier.

Results

Coding resulted in seven categories of "Questions/Concerns" and five categories of "Barriers" (Table 1). Given the small number of coded responses in some categories, only the most commonly coded categories are discussed below.

Table 1.
Categories of Educator Response for "Barriers for Parents" and "Questions/Concerns of Parents"

	Proportion of Participants Reporting	Educator Trained to Respond
Questions/Concerns of Parents
Strategies to use to get children to eat well	8/11	No
How to address weight issues with obese children.	2/11	No
Whether or not to give supplements to children	1/11	Did not report
How much weight to gain during pregnancy	1/11	Yes
How to present food to children	1/11	Yes
What are appropriate serving sizes	1/11	Yes
How to find affordable nutritious foods	1/11	Yes
Barriers for Parents
Ineffective parenting strategies & knowledge of child development	8/11	No
Cultural beliefs & traditions	8/11	For some issues
Resistance by children & spouses	7/11	No
Inadequate parental motivation	1/11	Did not report
Inaccurate parental beliefs about income & availability of appropriate foods	2/11	Yes

Common Categories for "Questions/Concerns of Parents"

The most common category under "Questions/Concerns of Parents" was "strategies to get children to eat well." For example, one of the educators reported that, "I hear all the time that my--my kids will only eat white bread - my kids will only eat white pasta--my kids won't eat any vegetable except carrot." Another educator indicated that, "the parents that I work with, they are really concerned about their children and the vegetable part you know, they [the children] don't want to eat the vegetables--and how they can make them eat their vegetables." This issue of how to get children to eat vegetables, in particular, was reported as a pressing parental concern by the majority of the educators.

Educators generally reported feeling inadequately trained to provide parents with effective strategies to get children to change their eating habits. They indicated that when they try to teach parents how to keep their children from becoming overweight, parents often give up because they cannot get their children to eat healthier foods. For example, educators described, "so I will say--give them vegetables, but then the kids refuse so they sometimes--don't buy anymore [vegetables]," and "so while I try to help them--[but] some just say that they [the kids] just want to eat pure meat." The types of parental concerns for which educators did feel prepared to handle were those dealing directly with nutritional issues, such as appropriate serving sizes and how to find affordable nutritious foods. These concerns were reported much less frequently than were those concerns related to changing children's eating habits.

Barriers for Parents

The most common categories within "Barriers for Parents" were "parenting strategies/knowledge about child development" and "cultural beliefs/traditions".

Parenting Strategies/Knowledge About Child Development

When describing parenting strategies educators explained that, "they [parents] often don't feel in control of what their children eat," "just to get the kids to quiet down, they give them food." Other examples of ineffective parenting or feeding strategies included "using food--dessert and junk food as a reward for--for eating well" and forcing and pressuring children to eat certain foods. Educators also indicated that parents do not know what to do when their children do not eat what they ask them to. They report that parents say, "If they don't eat--what are the consequences, what do I do?"

Resistance from Family

A similar parenting-related obstacle to making changes in nutrition-related behaviors was resistance from children and spouses. Just as parents voice concern with getting their children to eat better, educators reported that this resistance from children is a significant barrier impeding behavior change in families. Again, the most common source of resistance from children cited by educators centered on eating vegetables. As one educator described, "I guess it's one of the hardest part--vegetables, how do you feed vegetables to the children." Confirming this statement, another educator stated, "Yeah, I agree. It's an obvious thing that they are having problems with." Resistance to change, however, was also reported to derive from spouses. Educators describe that sometimes, "the obstacle is the husband," or "maybe they [the mothers] want to change, but it is really difficult for them to go to change because of the men in their lives. They [the men] want the taste certain ways."

Educators uniformly reported that they were not prepared to help families overcome these barriers of ineffective parenting and resistance from family members. For example, when asked what they do to address the issue of parents feeding their children junk food to quiet or comfort them, educators responded that, "I tend to ignore it, because I don't really know how to deal with it--it's a little tough." As one educator explained, "if you are working with a family and one of the issues is that you know the children don't want [to eat] vegetables or don't want to drink water--you don't find in your curriculum those caveats of how one would address that--you may be just teaching milk and milk products or you may be teaching fruits and vegetables--but the other caveats of how you move if there (are) eating problems with the children for whatever reason, usually we don't find necessarily in those curriculum how one move(s) on and address(es) (those) parent-related issue(s)."

In an attempt to provide parents with some form of advice, educators were therefore left searching for information. Some reported sorting through the vast quantities of sources on the Internet, while others resorted to using materials in the office that were developed for other purposes or resources not directly related to the intersection of parenting and nutrition. However, they reported that the little information they do access is not readily available when they need it or that "the timing isn't necessarily where it needs to be."

Some turned to other parents in the group to give tips from their own experiences or suggested strategies to get around the parenting issue rather than to address the issue directly. For example, educators suggested that parents sneak vegetables into soups or serve them with dressing. Some educators reported feeling uncomfortable addressing the issue because the information was not part of the regular curriculum and they did not want to single out individual parents in front of the group: "I don't really feel comfortable saying well look here--I don't want to make an example out of the parent" and "I don't know what to say [to the parents]."

Cultural Beliefs/Traditions

In addition to "resistance from family," educators also commonly identified barriers related to "cultural beliefs/traditions." For example, one educator reported that, "my experience--it is not every time--you know, the Hispanic population--believes that our children that is a little bit chubby is--you know, their way to go because, you know, as it looks healthy and looks good." Similarly, educators described that, "they [parents from certain cultures] are teaching their children you have to eat everything on your plate" because this is what they were taught when they were young. While a few of the educators reported feeling uncomfortable addressing these cultural issues, others reported many successful strategies, such as "you can kind of qualify your statement--and not attack them personally--that their beliefs are valuable but maybe there's another opinion they may want to consider." Similarly, "Instead of saying 'no you cannot eat that,' I just said 'oh, that is a great food if we can just change it a little bit,' and help them to see that the change is good without telling them what they doing is wrong."

Discussion

Results from these study revealed that parents lack the skills necessary to effectively implement new nutrition information with their children and educators lack the understanding of parenting and child development that is required to address these issues with parents. Educator responses indicate that parents express frustration related to implementing changes in feeding practices that reflect the use of ineffective parenting strategies. For instance, educators related that parents express a lack of control over what their children eat and commonly give up because of children's "refusal" to eat what parents serve. These types of parent-child interactions reflect parents' inability to consistently set boundaries with their children around food.

Additionally, educators do not feel prepared to adequately respond to these frustrations. Instead, they report ignoring the issue, asking for tips from other parents, or searching for resources on the Internet. By not directly addressing the underlying parenting behaviors, many parents are left using ineffective techniques that may deteriorate rather than improve child nutrition and weight. As one educator pointed out near the end of one focus group, "we tend to somehow separate parenting from feeding their children--as if they are two different things and it is really even in two different disciplines." However, given the frustrations encountered by the educators in the current sample, this may not be the most effective approach.

While there are some examples of the incorporation of a parenting framework with nutrition education (for example, Satter, 2000), a recent review of the field noted a lack of family systems approaches to child overweight and called for programs to begin thinking about parenting change as the mediator in the process between programming and child weight control (Kitzmann & Beech, 2006). However, the application of these types of approaches remains limited by funding constraints that exist within programs such as EFNEP and FSNE.

Conclusion and Recommendations

These results indicate that parenting issues are being raised in federally funded nutrition classes despite the limitations on class content and that educators are not equipped to respond in an effective manner. Thus, nutrition programs would benefit from the inclusion of parent resources to teach parents how to lead their children toward healthy behavior and educator training on these issues. While some EFNEP and FSNE educators have many years of experience and extensive training in nutrition and nutrition education, most have no specific training on parenting, despite the fact that all EFNEP and many FSNE clientele are parents or pregnant women.

Four recommendations toward an integrative approach are made. First, nutrition education programs should incorporate parenting and child development information into the curricula. While there are constraints with federally funded programs, information that directly relates to the feeding and nutrition of children should be considered. Second, to improve educators' capacity to respond to parents' concerns, information about the effects of parenting styles on child nutrition should be included in training. Third, nutrition educators must be provided with educational tools to effectively respond to the concerns raised by parents. Finally, ongoing, convenient resources regarding parenting, child development, nutrition, and how to use their knowledge to prevent childhood overweight need to be available to parents and educators.

Acknowledgements

This project was supported by funding provided to the Families with Young Children workgroup from University of California Division of Agriculture and Natural Resources. The authors would like to thank the University of California Cooperative Extension educators who participated in this research. Correspondence regarding this manuscript should be addressed to Lenna Ontai, University of California, Department of Human and Community Development, One Shields Ave., Davis, CA 95616 (email: lontaigrz@ucdavis.edu).

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